Provider Demographics
NPI:1861253296
Name:GONZALES, SHANNEN D (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:SHANNEN
Middle Name:D
Last Name:GONZALES
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337 GUSDORF RD STE G
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6297
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1337 GUSDORF RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6294
Practice Address - Country:US
Practice Address - Phone:575-758-4337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOT-2023-0155225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist